Prikaz sluËaja / Case report
“Double fire” — rijetka, a joπ ËeπÊe neprepoznata
aritmija
“Double fire” — a rare and commonly unrecognized
arrhythmia
Zoran BakotiÊ*, Ante AniÊ, Marin BiπtirliÊ, Albino JoviÊ
OpÊa bolnica Zadar, Zadar, Hrvatska
Zadar General Hospital, Zadar, Croatia
SAÆETAK: Dvojna fiziologija provoenja atrioventriku-
larnim (AV) Ëvorom, odnosno prisutnost tzv. sporog pu-
ta, prema raznim studijama, elektrofizioloπkim ispitiva-
njem se moæe dokazati u do Ëak 35% ljudi. Meutim, kod
samo manjeg broja on ima i kliniËki znaËaj.
Prikazujemo sluËaj pacijentice s vrlo rijetkom elektro-
fizioloπkom manifestacijom aktivnog sporog puta, dvo-
strukog odgovora ventrikula na jedan atrijski kompleks.
Problem je uspjeπno rjeπen radiofrekventnom ablacijom.
Ovakav naËin provoenja AV Ëvorom vjerovatno je i
znatno ËeπÊi nego πto se opisuje u literaturi, ali se na
æalost rijetko prepoznaje te je uglavnom refraktoran na
medikamentoznu terapiju.
KLJU»NE RIJE»I: dualna fiziologija atrioventrikulranog
Ëvora, “double fire” fenomen, radiofrekventna ablacija.
Prikaz sluËaja
Prikazujemo sluËaj 62 godiπnje pacijentice naruËene na in-
vazivnu kardioloπku obradu zbog uËestalih palpitacija te in-
tolerancije napora praÊene opresijama u prekordiju. Od rani-
je se lijeËi zbog arterijske hipertenzije i hiperlipidemije, a
zbog palpitacija u terapiji ima i propafenon 2x150 mg te ve-
rapamil 180 mg.
VeÊ na rutinskom 12-kanalnom elektrokardiogramu kod pri-
jema prepoznat je potencijalni uzrok tegoba. Naime, prisut-
ni su brojni ventrikularni kompleksi koji po morfologiji odgo-
varaju supraventrikulnim ekstrasistolama (SVES), bez vid-
ljive atrijske aktivnosti, a u uskoj vezi s prethodno uredno
provedenim sinusnim kompleksom (Slika 1). U 24-satnom
kontinuranom snimanju EKG zabiljeæeno je viπe od 10.000
takvih SVES. Ehokardiografski se radi o strukturno zdravom
srcu oËuvane sistoliËke funkcije, a koronarografijom je is-
kljuËena okluzivna bolest epikardijalnih arterija.
Cardiologia CROATICA
SUMMARY: Dual atrioventricular node (AV) pathway
physiology or the presence of so-called slow conduction
pathway is according to various studies demonstrable in
up to 35% of normal people during electrophysiology
study. In only a small number of them, it has a clinical
significance.
We present a case of a patient with a very rare electro-
physiological manifestation of active slow pathway, dou-
ble ventricular response to one atrial complex. The prob-
lem was successfully treated with radiofrequency abla-
tion.
This form of conduction via AV node is probably much
more common than it was previously described in the li-
terature, but unfortunately it is rarely recognized and is
generally refractory to medical therapy.
KEWWORDS: dual atrioventricular node physiology,
“double fire” phenomenon, radiofrequency ablation.
CITATION: Cardiol Croat. 2014;9(1-2):44-47.
Case study
We present a case of a 62 year-old woman admitted for fur-
ther evaluation because of frequent palpitations and effort
intolerance accompanied by precordial oppressions. She
has been treated for arterial hypertension and hyperlipi-
demia since earlier, and takes propafenone 2x150 mg, and
verapamil 180 mg in her therapy for palpitations.
A potential cause of problems was recognized already on a
routine 12-lead electrocardiogram at the time of admission.
In fact, there are numerous ventricular complexes that ac-
cording to their morphology correspond to supraventricular
extrasystoles (SVES), with no visible atrial activity, and are
closely related to the previously duly conducted sinus com-
plex (Figure 1). More than 10,000 such SVES were recor-
ded in the 24-hour continuous ECG recording. Echocardio-
graphy showed that it is a structurally normal heart with pre-
served systolic function, and coronary angiography exclud-
ed coronary artery disease.
2014;9(1-2):44.
Figure 1. Sinus rhythm with lot of narrow QRS extra beats, without preceding P wave. It is difficult to differentiate whether it
is ectopic activity from the AV junction (His region) or dual conduction of one P wave through both fast and slow pathway to
ventricle.
OdluËili smo se za elektrofizioloπko ispitivanje (EPS). Ba-
ziËnim intrakardijalnim elektrogramima potvrena je sumnja
da se radi o tzv. “double fire” fenomenu, odnosno dvostru-
kom atrioventrikularno (AV) provoenju. Na jedan atrijski
kompleks dolaze dva ventrikularna od kojih je prvi proveden
brzim, a drugi sporim putem (Slika 2a i 2b). Standardnim
EPS protokolom dokazana je dualna fiziologija AV Ëvora,
iskljuËeno je retrogradno provoenje, a nije inducirana ta-
hikardija niti ev. “eho” udari. U regiju sporog puta postavljen
je ablacijski kateter te se nakon nekoliko kraÊih aplikacija
energije u potpunosti eliminira dvojna AV fiziologija s is-
kljuËivim provoenjem kroz brzi put (Slika 3a i 3b). Aritmija
se ne javlja niti nakon primjene izoproterenola. Otpuπtena je
kuÊi bez antiaritmika.
2014;9(1-2):45.
Electrophysiology study (EPS) was performed. Basic intrac-
ardiac elektrograms confirmed the suspicion that this is the
so-called “double fire” phenomenon, or dual atrioventricular
(AV) conduction. Two ventricular complexes come to one
atrial complex, of which the first is conducted by the fast and
the second by the slow pathway (Figure 2a and 2b). Stan-
dard EPS protocol proved dual AV node pathway physiolo-
gy, excluded retrograde conduction, and induced no tachy-
cardia or “echo” beats. After a few short energy applications
in the region of the slow pathway, dual AV node physiology
was completely eliminated, only with conduction via the fast
pathway (Figure 3a and 3b). Arrhythmia was not inducible
even after the application of isoproterenol. She was dis-
charged home without antiarrhythmics.
Figure 2a.
Intracardiac recording
during electrophysiology
study.
Cardiologia CROATICA
Figure 2b. Schematic presentation of pulse propagation from atrium to ventricle: First atrial (sinus) impulse is conducted
through both fast and slow pathway to the region of His, and down to the ventricle (1:2 conduction). Second atrial stimulus is
blocked in the atrioventricular node which is still refractory from the previous depolarization by slow pathway. Third atrial
impulse is conducted only by fast pathway. (HRAd — high right atrium; HISd — region of His with its potential; RVd — apex
of the right ventricle).

Figure 3a.
ECG after success-
ful ablation in the
slow pathway re-
gion — intracardiac
recording.

ZakljuËak
Dvojna fiziologija provoenja AV Ëvorom, odnosno prisut-
nost tzv. sporog puta, prema raznim studijama, elektrofizio-
loπkim ispitivanjem se moæe dokazati u do Ëak 35% ljudi1-2.
Fenomen dvostrukog ventrikularnog odgovora na jedan at-
rijski kompleks prvi je opisao Csapo 1979. godine i nazvao
Conclusion
Dual AV node pathway physiology or the presence of so-
called slow conduction pathway is according to various stud-
ies present in up to 35% of people during EPS1-2.
The phenomenon of dual ventricular response to a single
atrial complex was first described by Csapo in 1979 and cal-

Cardiologia CROATICA 2014;9(1-2):46.

 Figure 3b. ECG after
successful ablation
in the slow pathway
region — standard
12-lead ECG.

ga je “double fire” ili “non-reentrant” tahikardija3. Rijedak je
jer zahtjeva posebne karakteristike oba puta — anterograd-
nu provodljivost i retrogradni blok, a spori put mora biti do-
voljno spor da dopusti His-Purkinjeovom tkivu da oporavi
podraæljivost nakon prethodne stimulacije4-6. Zbog toga fe-
nomen provodljivosti 1:2 nije konstantan, AV Ëvor se neujed-
naËeno depolarizira, pa su Ëesto prisutni i razliËiti oblici
funkcionalnog AV bloka (PR prolongacija ili Wenckebach).
Na vanjskom elektrokardiogramu to se manifestira nepravil-
nim ventrikularnim ritmom, a odnos s P valom je ponekad te-
πko pratiti. Zato i nije neobiËno da se ova aritmija teπko pre-
pozna, a kod bræe frekvencije i niæe voltaæe P vala lako za-
mjeni za npr. fibrilaciju atrija. Dominantan simptom su pal-
pitacije, a u literaturi su opisani sluËajevi tahikardiomiopatije
uzrokovani ovom aritmijom, uspjeπno rjeπeni ablacijom spo-
rog puta7-9. Ovi pacijenti u pravilu nemaju kruæne tahikardije
koje su tipiËne za aktivni spori put, kao πto je atrioventriku-
larna nodalna kruæna tahikardija.
Loπ odgovor na medikamentoznu terapiju (zbog rezistencije
sporog puta na veÊinu klasiËnih antiaritmika) i moguÊnost iz-
ljeËenja radiofrekventnom ablacijom, nameÊe potrebu da
razmiπljamo o ovom tipu aritmije koja se moæe prepoznati
veÊ iz standardnog 12-kanalnog elektrokardiograma. Na-
ravno, za dokaz je ipak potrebna elektrofizioloπka studija.
Received: 12th Jan 2014; Updated 19th Jan 2014; Accepted 30th Jan 2014
*Address for correspondence: OpÊa bolnica Zadar, Boæe PeriËiÊa 5, HR-23000
Zadar, Croatia.
Phone: +385-23-505-505
E-mail: zbakotic@gmail.com
led it a “double fire” or “non-reentrant” tachycardia3. It is rare
because it requires special characteristics of the both path-
ways — anterograde conduction and retrograde block, while
the slow pathway must be slow enough to allow the His-
Purkinje tissue to recover excitability after previous stimula-
tion4-6. For this reason, the conductivity phenomenon 1:2 is
not constant, the AV node is inconsistently depolarized, so
different forms of functional AV block (PR prolongation or
Wenckebach) are often present. It is manifested by irregular
ventricular rhythm on the external electrocardiogram, and
the relation with the P wave is sometimes hard to follow. So
it was not surprising that this arrhythmia is hard to recog-
nize, and at faster frequency and low voltage of the P wave
it can be easily confused for e.g. atrial fibrillation. The dom-
inant symptom are palpitations, and literature has described
the cases of tachycardiomyopathy caused by this arrhyth-
mia, successfully treated with radiofrequency (RF) ablation
of the slow pathway7-9. These patients typically have no re-
entrant tachycardia typical for active slow pathway, such as
atrioventricular nodal reentrant tachycardia (AVNRT).
A poor response to medical therapy (due to resistance of the
slow pathway to most classic antiarrhythmics) and the pos-
sibility of the treatment with RF ablation, forces us to think
about this type of arrhythmia that can be recognized already
from the standard 12-lead electrocardiogram. Of course,
electrophysiology study is required to prove it.

Literature

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3. Csapo G. Paroxysmal nonreentrant tachycardias due to simultaneous conduction in dual atrioventricular nodal pathways. Am J Cardiol. 1979;43(5):1033-45.
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2014;9(1-2):47. Cardiologia CROATICA